Double Trouble:
Tongue and Lip Tie Twin case study
Introduction
Ankyloglossia and shortened maxillary
frenula (tongue and lip tie) often cause difficulty with breastfeeding. Poor
latch with subsequent maternal nipple pain, poor milk transfer, failure to thrive
and symptoms of reflux and colic have been described in the literature.
Ankyloglossia (tongue tie) is a congenital anomaly observed
in newborns and children, and is characterised by an abnormally short lingual
frenulum. The tight frenulum can cause decreased tongue mobility to varying
degrees. (2). In order for a breastfeeding infant to properly latch onto the
mother’s breast, the infants tongue must be able to thrust to the edge of the
lower gum and cup around the areola and the mothers elongated nipple. The
infants tongue movement may be restricted by an abnormal lingual frenulum. In
breastfeeding the infant is unable to form an appropriate seal. This frequently
results in sore nipples for the mother. Ineffective sucking in the newborn may
also result in insufficient milk drainage in the mother, which in turn may lead
to mastitis, decreased maternal milk supply, and eventually poor infant weight
gain secondary to non-nutritive sucking. (3). A frenotomy, simple “snip” with a
blunt-ended scissors is usually all that is needed and bleeding is minimal. It
is less traumatic than ear piercing, and much less invasive and painful than
circumcision. Immediately after the frenotomy is done, the infant is placed
back on the breast, and the latch adjusted. There is usually immediate
improvement in milk transfer and maternal comfort. (8).
During latching onto the breast, is also the importance of
the upper lip flanging outward. The normal breastfeeding motion is best achieved when the baby can
widely open the mouth. This wide opening is best achieved when the baby is able
to flange the upper lip outward, allowing the mucous membrane portion of the
lip (rather than the dry outer portion) to contact the breast. This allows for
a better seal, which is the first step in generating the negative pressure for
breastfeeding. (7). If the upper lip tie is tight enough the infant may also
have trouble feeding from a bottle. Dr. O'Callahan and colleagues (2013) found
that 37% of babies with tongue tie also had a current upper lip tie (ULT).
Those ULTs were treated routinely as part of the study. While they were not
specifically separated out and studied, it shows the importance of treating the
baby to maximize breastfeeding outcomes. Many practitioners who routinely treat
tongue-tied babies feel that this number likely underestimates the number of
babies who would benefit from a lip tie revision. (7)Reflux in infants poses many challenges for the parent/infant relationship. Aerophagia is a poorly studied but commonly seen phenomenon in breast and bottle fed infants. Aerophagia from the Greek “aerophagein” means “to eat air”. Post-feed aerophagia can be seen with higher rates in infants with tongue tie and possible lip tie. When the infant attempts to latch and has an ineffective flange/seal and dysmotility of the tongue on swallowing, there may be an increase in swallowing of air, leading to post-feeding gastric distention, colic and possible reflux. This is often seen clinically in infants with ankyloglossia and/or shortened maxillary labial frenula (tongue and lip tie). Aerophagia is often seen after feeds and is diagnosed by auscultation (examination with a stethoscope) during feeding, presence of colic-like symptoms after feeding, and gastric distention immediately after feed and can be seen on flat plate X-ray with enlarged gastric bubble. The increase in gastric pressure may overcome the lower esophageal sphincter pressure and gastric contents may reflux into the upper airway. This may be confused with other types of reflux disorders and result in misdiagnosis and improper treatment. (9).
Case
Study
Kate
and Patrick parents to 4 boys were referred to me for feeding concerns of their
twin boys Dyson and Cadan by their chiropractor.
Dyson
and Cadan mono di twins were born at 32 weeks weighing 1.8kg and 1.7kg. They
were in the NICU for 4 weeks, on CPAP for 2 days. Kate expressed breastmilk for
the boys for the duration of the NICU stay where they were tube fed initially
then moved onto bottle. Exclusive pumping without the baby stimulating the
breast, Kate started having some supply concerns. Kate had breastfed her
previous 2 boys, but decided with the inconsistency of supply and there being
2, she decided not to continue breastfeeding.
Dyson
was posseting and actually vomiting 2-3 of his feeds per day. The pediatrician
diagnosed both boys as having reflux. They were put onto Gaviscon for a few
days and then moved onto Nexium, which Kate was not very keen on. Kate and
Patrick took the boys to a chiropractor for the reflux. The reflux did improve
but still had concerns. The boys were having trouble latching onto the bottle.
It was taking around 90min for the boys to drink a bottle, and it was getting
worse. Chiro suggested that they contact me, to assist with feeding concerns.
On
seeing the boys, they would fatigue quickly while drinking bottle. Battling to
maintain latch onto the bottle. Examining their mouths, I suspected that they
had posterior tongue ties and lip ties. This was potentially the reason for the
feeding difficulties and reflux. I referred them to a paediatrician for
evaluation. I discussed suck training exercises in order to increase the muscle
tone, as well as different teats to use and paced bottle feeding techniques. Parents took the boys to an ENT that their family has been seeing for many years. The ENT told the parents that there is no such thing as posterior tongue ties. Kate phoned me, as now having concerns. She can see that there is a problem, but the twins were seen 3 times per day in ICU for 4 weeks and the pediatrician seeing them never once said anything about tongue / lip tie. There trusted ENT says there is no such thing. Now she must trust the word of a nurse over 2 specialized Drs. I sent her all the information that I had on the topic, with my rationale for why I think that Dysan and Cadan have posterior tongue ties. Kate and Patrick were now sitting with 3 different diagnoses; reflux; tongue tie; and no tongue tie. An extremely stressful and confusing situation. She decided to pursue it with an ENT at Parklane Clinic. In the 6 weeks between seeing me, and seeing the ENT, the twins only gained 300g.
This ENT confirmed and diagnosed posterior tongue tie and lip tie. He performed a frenotomy, lip revision and put in grommets. As the boys came around from the anaesthetic, she was advised to feed them immediately. Kate said that there was a definite difference already in how the boys latched onto the bottle. Over the next few weeks there was a dramatic improvement, they were different babies. Much more content, and they gained 400g in 1½ weeks. The twins’ weight gain has steadily improved; they are now “klapping” their bottles. Kate also describes the difference in feeding them, where previously not even wanting a bottle, to now getting excited when they see it coming. They have recently started solids and are doing well.
Discussion
Parents want to do the best for their children and prevent
or fix anything that prevents them from thriving. In order to do this, they
rely on health care professionals to assist them. If we look back through the case
study, Dysan and Cadan were compensating, when this became too difficult, they
started presenting with symptoms. The symptoms were treated, not the reason for
the symptom. Kate and Patrick and other parents seek help from
various health care professionals. Paediatrician may treat the reflux with PPI,
chiropractors, physiotherapists, sleep trainers, dieticians, clinic sisters,
pharmacists etc. each doing best to help the parents and the baby. This all
comes at a financial cost, putting parents under strain as well. Reliable information about how tongue tie truly disrupts latch quality wasn’t available until 2008, when an ultrasound study showed what the tongue does during breastfeeding. This information presented a paradigm shift in the understanding of infant anatomy and physiology with respect to breastfeeding and had a huge implication for how restriction of normal tongue movement could impact successful breastfeeding. (10).
Tongue ties are not always obvious, especially posterior tongue ties. It takes training, reading and practice in diagnosing tongue ties. Education of health care professionals on the signs of potential tongue and lip tie needs to be done. In twins case:
-
Reflux
-
Poor weight gain
-
Fatigue during feeding, taking long to feed.
-
“colic”, fussy babies, fussy eaters
As well as training more health care professionals on how to
assess a baby for tongue tie, and if a health care professional has the
knowledge, to actually be assessing for ankyloglossia routinely. Cadan and
Dyson’s tongue & lip tie could have been picked up in the NICU. If more babies were diagnosed with tongue-tie properly, not
only would moms who want to breastfeed have a better chance of succeeding, but
the long term complications of tongue & lip ties could be prevented. (5).
Samantha Crompton RN.RM.RCM.RP. SACLC
References
1.
Guidelines to the writing of a case
study. Dr. Brian Budgell, DC, PhD*.J Can Chiropr Assoc 2008; 52(4) 199.
2.
http://www.cps.ca/documents/position/ankyloglossia-breastfeeding.
20/9/2015. Ankyloglossia
and breastfeeding. Anne Rowan-Legg MD,
Canadian Paediatric Society , Community Paediatrics Committee. 2015;20(4):209-13.
3.
Newborn
Tongue-tie: Prevalence and Effect on Breast-Feeding. Lori A. Submitted, revised, 15 October 2004.From
the Regions Family and Community Medicine Residency Program (LAR, DJM-K),
Department of Family Medicine and Community Health (NJB), University of
Minnesota Medical School, St. Paul, and the HealthPartners Research Foundation
(TAD), St. Paul, MN.
4.
Tongue-Tie and Breastfeeding: a review
of the literature. Janet Edmunds. Breastfeeding Review 2011; 19(1):
19–26.
5.
http://www.bestforbabes.org/booby-trap-docs-who-wont-snip-tongue-tie-thousands-of-breastfeeding-moms-babies-suffer/.
22/9/2015. Booby Trap: Docs Who Won’t Snip Tongue-Tie, Thousands of
Breastfeeding Moms & Babies.
6.
http://www.perioimplantadvisory.com/articles/2012/7/ankyloglossia-tongue-tie-release-using-dental-lasers.html.
12/10/2015. Ankyloglossia (tongue tie) release using dental lasers. Dr Laurie
Kobler.
7.
http://www.drghaheri.com/blog/2014/3/6/how-does-an-upper-lip-tie-affect-breastfeeding.
7/9/2016. How does an upper lip tie affect breastfeeding. 16 march 2014.
8.
CONGENTIAL TONGUE-TIE AND ITS IMPACT ON BREASTFEEDING. Elizabeth Coryllos, MD, MSs, FAAP, FACS,
FRCSc, IBCLC. American academy of paediatrics.
9.
Aerophagia Induced Reflux in Breastfeeding
Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and
Lip Tie). Scott A Siegel. Int J Clin Pediatr. 2016;5(1):6-8.
10.
http://www.drghaheri.com/blog/. How the system
can fail breastfeeding families. 8/9/2016.
